MEDICARE: PAIN CLINIC MANAGEMENT GROUP, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1225302821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN CLINIC MANAGEMENT GROUP, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 772211
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48277-2211
Country	:	US
Telephone Number	:	800-444-6110
Fax Number	:

Provider Business Practice Location Address
First Line	:	35634 DEQUINDRE RD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4288
Country	:	US
Telephone Number	:	586-978-7250
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. JASON PETER
Credential	:	DO
Telephone Number	:	586-978-7250

Provider Enumeration Date	:	02/28/2012
Last Update Date	:	03/11/2026

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